When "Lisa" came into my office I could tell she was very upset. "I don't know what happened. All of a sudden I started eating and I couldn't stop! I just can't control my eating. There must be something wrong with me. My body just can't handle food like normal people do. I need to watch everything I eat. I'm so scared to lose control like that."

Lisa's torment may sound familiar to you. I know that when I was in my eating disorder, I too described binges very similarly. I remember telling my therapist that it was like a wave that just came over me, out of the blue. I was sure that my body was somehow to blame.

Lisa's reaction is typical too. Since she can't figure out what brought on the binge to begin with, she can only try to fix what she is aware of: the food. But becoming more controlling with food and more restrictive in her eating doesn't work; it only makes the problem worse.

So if trying to control the food isn't the answer, if restricting her eating only makes it worse, then what is Lisa to do? Sometimes we have to admit that doing more of the same is not the answer, especially when it always results in the same outcome. In the words of Monty Python, "And now for something completely different.!"

Focusing our attention on what foods Lisa binges on is not helpful. Becoming aware of what happened before the binge is much more constructive. When a client comes to me and says she binged, I help her to understand that the binge is just an opportunity to learn about her self and to become aware of what is going on inside. Most women who have eating disorders are not very mindful of what is happening within themselves in the moment. Most of the time, they are ruminating about the past or worrying about the future. But the present moment is a blank, they are unaware of what they are experiencing in the moment.

To become aware of what led up to a binge I often will help a client "dissect" the binge. I ask them to talk about the 24 to 36 hours before the binge began. We try to recreate what happened in detail: who she interacted with, what she ate, what she was thinking, what she was feeling. I often ask clients, "When did you know you were going to binge? What was the first sign that you were headed for trouble?" Not surprisingly, the majority of the time, clients had an inkling of a sign in advance of the binge. I used to call these signs the "Uh Ohs".

Does this sound familiar? A tiny voice in the back of my head would be saying "uh oh something's wrong" hours before the binge even began. If I didn't pay attention, I would miss it. The voice would then just get louder, "Uh Oh! Something is definitely not OK." If I continued to ignore it or not pay attention it would turn into "UH OH! Do something quick!" But if my unawareness continued, it would soon be, " UH OH! Oh forget it! Too late! Let's eat!"

If my clients become more aware, more mindful they are more able to catch the "uh ohs" as soon as possible, when they are still very quiet voices. When the uh ohs are small, they can be handled more easily than if they are loud and extreme. When I described this to Lisa, she came up with a wonderful analogy that helped her to "see" what she needed to do. (And you know how I love analogies.)

She said bingeing was like going over a waterfall in a small boat. If she was far back upstream on the river and she paid attention to quiet signs (the sound of the waterfall, the mist of the waterfall in the distance, the acceleration of the current of the stream) she would become aware that "uh oh", there was a waterfall ahead. She would be able to paddle to shore to not go over the waterfall. If she was not paying attention or ignored the quiet signs, she would be closer to the waterfall and it may be hard for her to get to shore by herself. When she became aware that "Uh Oh!" there's a waterfall ahead, she would have to ask for help from someone who could help her bring her boat to the shore. But if she still did not pay attention or continued to ignore the signs (which by the way are becoming ever louder and more apparent - UH OH!) she would be so close to the falls that it would be inevitable that she would go over - " UH OH , too late! Let's Eat!!!"

By dissecting a binge we learn what our "uh oh's" are for us: what emotions, relationships, feelings, body sensations, thoughts and events are likely to cause us distress and if not taken care of can trigger a binge. Let's go back and look at what Lisa was dealing with on the day before her binge.

At first Lisa focused on the food aspect of the binge. "I had such a craving for sweets and on my way home I kept fighting off the urge to pull into every convenience store. Finally I broke down and bought a huge bag of cookies and since I knew I was going to get rid of it, I bought some cake and ice cream too." I asked her to think of any associations to the sweets, what they meant to her at that particular day.

"Well, it could be that at a meeting at work today someone brought in a tray of sweets. I wouldn't let myself have one even though I really wanted one." I commented, "I think we just found an "uh oh". But I'm sure there's more to this."

Lisa reflected, "I was really hungry when I binged, because I hadn't eaten much that day. I usually only have coffee for breakfast and a salad for lunch." (Did you just hear another "uh oh"?)

"Tell me about how you were feeling during the day?" I asked. Lisa related, "For some reason, I was a bit on edge ("uh oh") and I'm not sure why. Nothing really happened at work." She had been at a meeting led by her supervisor with seven of her coworkers. She just happened to be the only female at the meeting. At one point in the meeting her supervisor asked Lisa to make some copies even though she was not sitting by the door. "As I maneuvered my way around everyone else's chair to get to the door, I was annoyed that he asked me, a female, to make the copies. The guys who were closer to the door know how to make copies. Why didn't he ask one of them? But I know I shouldn't let it bother me, it's such a little thing." ("UH OH!")

"But it did bother you," I prompted. Lisa's face lit up as she realized, "Yeah! I was mad and felt belittled by him! I tried to make myself feel superior by turning down the sweets in the meeting. But I kept yelling at myself for letting it bother me at all (UH OH!) !"

"Is this the first time something like this has happened at work?" I asked.

"Oh no. He does things like this all the time at work. I tried to talk to him about it, but he dismissed my concerns," she replied. Her face became downcast as she realized, "I think I'm going to have to find a new job and I'm scared."

"Lisa, I think we found the biggest UH OH of them all."

As you can see by this example, if Lisa just focused on the cookies she would be missing what really was wrong. She learned how to pick up subtle signals that she was experiencing an emotion that she needed to deal with. Eventually with practice she became more mindful of her internal reactions to what was going on around her. She started making connections between these reactions and feelings and her cravings for binges. Working hard over time, she was able to learn how to handle these events without resorting to food.

*"Lisa" is a composite of many clients and is not the real name of her client.

Have you ever heard someone say: "It's not like it is brain surgery or something?" Sometimes people say this when they are referring to a task that appears to be understandable or simple. This is one way that eating disorder recovery is sometimes viewed. Many times, eating disorder recovery is viewed from the perspective that all one needs to do is eat in a normal way. From time to time, I have heard clients (as well as families of people with eating disorders) say, "I should be able to get over this quickly" or "why is this so hard? I know intellectually how to eat, and bingeing/purging/ starving/over exercising is not good for me. So, why can't I just stop?". And very recently, I heard someone say that eating disorders aren't brain surgery, and they should just be able to stop. This last statement touched me in a different way than the previous statements. Over a year ago, I had brain surgery for a hearing problem. Since that time, I have thought a lot about the similarities of major surgery recovery and the process of recovery from an eating disorder.

Eating disorder recovery may not seem to resemble brain surgery - but in fact it is my experience that they do have some things in common. There is a process involved with both. This process can have emotional, physical, and social aspects. This is a process that is sometimes frustrating and intolerable, and at other times, connected and empowering. The key component here is that both take time, persistence, and incorporate the individuality of the person going through the process.

Physical recovery from eating disorders and physical recovery from brain surgery are important pieces. People going through eating disorder recovery often feel disconnected from their bodies. Similar to how someone recovering from major surgery may be feeling. Certainly, there are physical differences, but relearning to eat and feed your body when recovering from eating disorders can be a daunting task. The same way that interacting with your body after surgery may also be overwhelming and scary at times. Likewise, identifying and listening to physical cues, in either the process of recovery from eating disorders or from major surgery, can be difficult and confusing. Many clients have said that learning to feel hunger is scary and exciting at the same time, much the same way it can be to experience one's body cues after surgery.

Separate (but connected) to the physical nature of recovery, is the emotional experiences of recovering. People recovering from surgery and people recovering from eating disorders may struggle when dealing with varying emotions. It can be part of the recovery process for individuals with eating disorders to learn to tolerate different emotions, much the same way people recovering from surgery may have many differing and conflicting emotions. For both sets of recovering people it can be important to understand the emotions, and also learn what they need to do in order to tolerate them.

Last is the social impact of recovering. People recovering from eating disorders often feel alone; sometimes feeling they are the only ones going through the struggle to recover from eating disorders. Feelings of isolation and disconnection are common experiences in both recovery processes. It is also likely that through the process of recovery there may be times when it is difficult to relate to others. It may be hard to connect with others. Especially if one is feeling different, relating and sharing (or making one self vulnerable) can seem overwhelming. It is not uncommon for both processes of recovery to be wrought with feelings of disconnection, isolation and feeling misunderstood by others. From both emotional and social aspects of the recovery, there may be anger or resentment for having to go through the process in the first place. There may be other times when one feels misunderstood by those around them, and one may feel confused by what is happening to them.

Recovery from surgery, as well as from eating disorders, is a complicated process. There may be days when things flow smoothly, and the once very present struggle seems miles away. Then there may be days when that struggle is the lens that you see your world through. These days can sometimes feel endless. But, as I have experienced, both professionally and personally, these days will not last forever and as time goes by and you move along your own individual path of recovery, these days will become fewer, and farther in between.

Eating disorders, as is brain surgery, are complicated. Both processes of recovery take time and the ability to be gentle with one self to discover, uncover, and heal. (Kathleen has fully recovered from the surgery and is doing fine.)

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​April–August 2005​Table of Contents:

Improving Body Image—Nicole Bailey

How Often Should I Eat? And Other Questions…—Elisa D'Urso-Fischer, RD

Improving Body ImageNicole Bailey

We each view life through a filter. Our perceptions of the world are shaped by the messages we receive from others throughout our lives. Our minds tend to distort what our eyes see, based on our beliefs. It is because of this that we cannot objectively see our own body, even in photographs or mirrors. Based on messages we have received throughout our lives, our brains distort our perception of our appearance. We are affected by these external messages whether we realize it or not. Images of women's bodies from television, movies, magazines, music videos and advertisements tremendously influence how we view our own bodies. Combating the critical nature of social expectations of the female form is challenging for every woman. Employing particular therapeutic techniques can be beneficial for improving one's own body image acceptance.

Body image is the personal picture we have in our mind of what we think we look like, and all of the thoughts, feelings, judgments and criticisms we have about what we think we look like. For most of us this picture is distorted and inaccurate and can lead to great dissatisfaction with our body.

Art therapy is grounded in the philosophy that establishing a relationship with one's personal visual world can lead to deeper understanding of the self. Art therapy helps us develop a visual relationship through making and changing images and symbols. Once this relationship is established we can use visual representations to positive means. Making art in a therapeutic setting allows us to depict what is perceived within our unconscious minds. Subsequently working with one's personal unconscious imagery can illicit profound insight and influential change.

Using art therapy to change one's body image can be very beneficial. Exploring personal symbols, as they relate to one's own body image, can bring to the conscious mind the personal beliefs and external messages we trust to tell us about our own bodies. Using this understanding as a basis we can begin to sympathize with ourselves and our bodies. Eventually understanding can lead to appreciation, and appreciation can lead to acceptance. The process of reevaluating how we see our bodies can only begin with an understanding of how we see the world. Using art in therapy is a perfect method to unlock these beliefs and begin to change them.

If you would like to try art therapy, I am hosting a workshop using art therapy to improve body image. Please see the box right for more information. Nicole Bailey is a second year graduate student in the Art Therapy Program at The Adler School of Professional Psychology.______________________________

How Often Should I Eat? And other Questions…Elisa D'Urso-Fischer, RD, LD

HOW OFTEN SHOULD I EAT?

Which is better, 3 meals a day or 6 small ones? Is "grazing" still recommended? Should I follow a meal plan?

These are only a few of the various nutrition related questions that many people struggle with on a daily basis. But, considering all my years of nutrition education, current research, and even the new Dietary Guidelines for Americans and the new Food Guide Pyramid, to find the best answer, we need to turn to the human body and observe how it functions.

"Hunger is one of the first, urgent, repetitive, internal experiences. If hunger is quickly followed by satisfaction, the infant learns that hunger is manageable" (Bloom, Gutwall, Kogel, Zahpiropoulos, Eating Problems: A Feminist Psychoanalytic Treatment Model; 1994). However, if hunger is not followed by satisfaction, it would seem that we learn that hunger is unmanageable. So, a critical guideline to when to eat is certainly "eat when you are hungry." For people with a history of restricted eating, whether it has been medically supervised diets or an eating disorder, knowing when you are hungry can be very difficult.

Scientific research is only beginning to identify the many changes that take place when we get hungry. There are biochemical substances that build up in our body that drive us to seek food and eat. A biologically sound guideline is to allow no more than 3 to 4 hours between meals and snacks. "This interval matches the liver's capacity to maintain blood glucose levels" (Herrin, Nutrition Counseling in the Treatment of Eating Disorders). Adequate blood glucose levels are essential for us to feel energized, and for us to maintain adequate serotonin levels which in turn help us to feel "okay." For many of us, when our blood sugar drops, we feel what I call the "blood sugar blues". overwhelmed, sad, anxious, indecisive, moody, and the list goes on.

According to Garner and Garfinkel in The Handbook of Treatment for Eating Disorders, initially, most people suffering from eating disorders are unable to interpret and act on internal sensations of hunger. Rather, it is eating at established regular intervals that can help in the re-calibration and re-establishment of hunger and fullness signals. In fact, many experts recommend that people experiment with even shorter intervals between meals and snacks, say every 2 to 3 hours to help decrease bingeing (Herrin, 2003).

Eating at regular intervals, whether it is every 2 or 3 or 4 hours requires some planning and some effort. It may require some nutrition guidance so that you can meet recommended food servings, and yet not feel anxious about overeating or feel like you are eating all the time. The research and literature on the recovery from disordered eating as well as my personal nutritional counseling experience, all support the value in making the effort to eat 3 meals plus 2 to 3 snacks spread throughout the day. We only are beginning to learn and document the biochemical and psychological benefits of what humans have been doing instinctively for thousands of years.

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September–December 2005​Table of Contents:

Recovering the Sense of Self—Amy Grabowski, MA, LCPC

Men & Eating Disorders: Refuting an Ancient Myth—Corey Cashen

Recovering The Sense of SelfAmy Grabowski, MA, LCPC

Editor's Note: Amy is in the process of writing a book about recovering from eating disorders. Occasionally we have printed excerpts from it. This is the beginning of a chapter about finding the sense of Self. You may want to read some previous excerpts on our website.

"Over the weekend, I went to an office party with my new boyfriend. It was the first time that he was introducing me to his friends and boss. He seemed really nervous and kept going into other rooms, just leaving me sitting there all alone. The critic in my head kept screaming at me, 'You're so fat that he can't stand to be seen with you! You are such a loser that he's embarrassed to be with you.' I could hear it but something different happened this time. Deep inside I felt something, not a voice but just a sense of knowing that the critic was wrong. I felt OK. I knew that he was just nervous and it wasn't because of me." Ann

Describing the Self is like trying to describe a beautiful color. It is difficult to put into words. But like recognizing the beautiful color once you've seen it, when you recover your sense of Self, it will feel familiar. Amanda described it well, "It's like trying to remember a song you've heard only once. But if you hear it again you remember it. And if you hear it again and again, over time you can sing it to yourself whenever you want."

The familiarity is because you were born with a sense of Self, and you were very expressive of your Self from age two or three on. Now, your Self is there hidden away below the surface; it may be covered in layers of defenses and "old trash", but it's there. Remember the analogy from chapter 2 about the President of the US being hidden away if the country were in attack? For whatever reason, in your personal history, it was not safe for you to be in your Self and your Self was hidden away for safekeeping. For some of you it was a constant gradual daily wearing away of your Self. For others it may have felt more like an explosion! Some of you remember feeling good about yourself until puberty, and others say they felt bad before they even entered preschool. It doesn't really matter how or when it happened, the effect was the same.

Speaking of puberty, there have been a number of studies and books written about the dramatic change and loss of self-esteem when girls reach early adolescence. As Mary Pipher writes in her book, Reviving Ophelia: "Just as planes and ships disappear mysteriously into the Bermuda Triangle, so do the selves of girls go down in droves. The crash and burn in a social and developmental Bermuda Triangle." Many of my clients have talked about Junior High School as being the most painful time of their life, like Rachel, "In third or fourth grade, I felt really confident, I liked myself a lot. I was comfortable in my body. I remember having eating contests. Who could eat the most? And standing up on the table and winning the eating contest. And it wasn't a binge! Oh no! I would eat and just forgot about it. I lost her in Junior High School. I wonder where is that person? Where did she go?"

I know what you are thinking, "Yeah, right. Everyone else who reads this book has a Self hidden away, but not me. I'm defective, I'm hopeless." That is just a Bully talking. As you will learn in the next chapter, the Bully is just trying to protect you from being disappointed. For years the parts have organized around a system based on the lack of Self and they are suspicious of any change to this system. They will try to protect the system because they don't trust that the Self will really stay and be there for them. Like the members of an orchestra whose conductor has been absent for a long time, it would take time for them to be assured that she will not leave again. Some of the parts may actually feel relieved that the Self is coming back, but other parts may feel threatened. They may actively try to sabotage this work we are trying to accomplish. (This is another reason to be working with a therapist.)

One of the problems that people encounter when trying to find their sense of Self is that the Self is physically subtle and verbally very quiet - and the parts are physically intense and verbally LOUD! The Self is easily out-shouted by the chattering and clamoring of the parts. As we all know, the squeaky wheel gets the grease - we give our attention to the parts who are the loudest. Often times also, because one or more of the parts are LOUD and very outspoken, they are the ones who you may identify with as being your "self". Because this false-self does not have the qualities of the Self, the mistaken thought of allowing this part to take over and be in charge, may be horrifying.

Sometimes people confuse what I mean by the sense of Self. They think of it as being "in control" or an optimistic cheerleader quality of confidence. While feeling in control and being confident are qualities of your Self, the Self is deeper than that. It is a deep-seated feeling of inner strength and wisdom within. When you are in your Self, you know that no matter what happens you can handle it, you have all the resources you need within you. And from this strength and knowledge, you calmly feel in control and confident.

Almost without exception, when someone doesn't have a sense of Self, they describe an inner emptiness that is very frightening. There is a deep profound sense that something is missing! The emptiness is where your Self is supposed to be. For example if I want to plant a rose bush I have to dig a hole. The hole is where the rose bush will be, the potential for the rose bush. But until the rose bush is planted, it's just a hole. The hole, the emptiness inside us, is the potential where you will experience the Self again. It was there, but now it's concealed and we're going to bring it out of hiding and put it back. One of the best side effects of recovering your sense of Self, is that the inner emptiness disappears! It gets filled, just as the hole disappeared as soon as you put the rose bush into it.

Our goal is to live our life in a state that Dr. Schwartz calls Self Leadership. It would be almost impossible to live our life in our Self perfectly all of the time. When life throws us a zinger, and it will, not because we are weak or defective - but because we are humans living in a human world - a part may react and need help. The Self will compassionately notice, and take the time to attend to her needs. This may mean pulling resources from other parts or from other people who can be trusted. The parts and Self can then return to its healthy new system.

Once you know what it feels like to be in your Self, you will be able to consciously "breathe into" that feeling again and again. It will not come naturally at first. Like learning a new language, at first it will feel foreign, but the more you use it the more comfortable and familiar it will feel. With practice you can become completely fluent. I encourage my clients to practice every day, perhaps starting with a morning ritual that includes intentionally getting in touch with their sense of Self. Amy Grabowski, MA, LCPC has been providing therapy with women struggling to recovery from eating disorders for 20 years. She recently recorded a relaxation CD "Imagine Being at Peace…." to quiet the chattering in your mind, relax your body and recover your sense of Self. For information to purchase the CD, please call her (773) 929-6262 ext 11 or contact her at awakeningcenter@aol.com

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Men and Eating Disorders: Refuting an Ancient MythCorey Cashen

The individuals within our society often characterize an eating disorder as being a female issue that arises from female problems. Not only is this stereotype grossly out of proportion with scientific data, but it also undermines the struggles and underlying conflict one must face during the phases of recovering from an eating disorders. Currently, research indicates that eating disorders can affect people of all ethnicities, races, socioeconomic statuses, sexual orientations, and even genders. In fact, it is estimated that one million men in America currently suffer from an eating disorder! While this fact alone is enough evidence to dispel the myth that eating disorders are strictly a female problem, it renders further exploration.​The occurrence of eating disorders in males is not a newly discovered epidemic. Many people who are aware of the occurrence of eating disordered males incorrectly assume that males only suffer from compulsive overeating. In actuality, there are documented cases of men suffering from anorexia nervosa dating back as far as the 1600s. It is now estimated that one in ten adults suffering from eating disorders and 20-30% of younger anorexics are males. The National Association of Anorexia Nervosa and Associated Disorders (ANAD) even makes the bold claim that "there are probably as many bulimic men as there are anorexic women."

Despite different societal (weight) expectations for men and women, the underlying conflicts associated with eating disorders are often very similar. When compared with females, men with eating disorders struggle with similar difficulties of emotional expression, anxiety, depression, control, and shame. In recent decades, dieting has become more acceptable in men, and it is possible that pressure from the media for men to diet has increased during that time as well. Also, while males of all sexual orientations can develop eating disorders, men with gender identity and sexual orientation issues appear to be at an increased risk when compared to males without these conflicts. Of course, these factors should not overshadow the many other conflicts, triggers, and causes of eating disorders that cannot be listed here.Improved awareness has made slow strides resulting in a recent increase of identified eating disorders in males. Unfortunately, due to a number of reasons, it remains difficult for these men to seek treatment once an eating disorder is identified. A common reason is that there are relatively few inpatient treatment programs available, the majority of which do not treat males. It is also common for males to avoid treatment because their disordered eating behaviors serve certain athletic goals, such as maintaining a weight class in wrestling. Society's idea of masculinity also deters males from seeking treatment, among other reasons. Surely, one fact is irrefutable: Eating disorders are not limited to females. They are a personal struggle that can affect anyone. Corey Cashen is a third-year graduate student in the clinical program at the Chicago School of Professional Psychology. ​